Schizophrenia/ psychotic disorders

What is the central theme of schizophrenia spectrum disorders?

• pschosis

What are the symptoms of psychosis?

• Hallucinations

• delusions

• disorganized thoughts, speech, or behavior

who first described disorder as “Dementia Praecox”?

• Emil Kraepelin

Who determined the presence of several types of schizophrenia?

• Eugen Bleuler

What are some schizophrenia biological influences?

• excess of dopamine activity in brain

• enlarged lateral and third ventricles

• total brain volume overall decresed

What are environmental influences of Schizophrenia? Sociocultural factors? ( Downward drift hypothesis)

• childhood trauma

• sociocultural factors:

  • Downward drift hypothesis: poor social conditions are seen as a consequence of, rather than a cause of, schizophrenia

  • Stressful life events are associated with exacerbation of schizophrenic symptoms and increased rates of relapse.

What is the prodromal period?

• period where deterioration and mood changes occur.

What is the first episode period?

• where psychotic break happens, some form of stress triggers it.

What is the acute illness period ( active psychosis)?

• where you see the hallucinations, delusions, thought distortion

• patients are at most risk during this period.

• medication is needed.

What is the stabilization period?

• discharged home.

• acute symptoms are diminishing

What is the maintenance and recovery period?

• symptoms are stabilized

• wont ever have and absence of symptoms

What is the relapses period?

• if patients don’t keep up with there medications they can relapse.

• increased stress is another cause.

What are some factors associated with a positive prognosis?

• Good premorbid adjustment

• Later age at onset

• Being female

• Abrupt onset precipitated by a stressful event

• Associated mood disturbance

• Good inter-episode functioning

• Brief duration of active-phase symptoms

• Minimal residual symptoms

• Absence of structural brain abnormalities

• Normal neurological functioning

• No family history of schizophrenia

What are the diagnostic criteria for schizophrenia?

• 2 or more of the following must be present

• one of the two symptoms have to be one of the top three

• Dellusions

• Hallucinations

• disorganized speech: disorganized thinking

• disorganized or catatonic behavior

• negative symptoms

  • STMPTOMS MUST LAST FOR AT LEAST 6 MONTHS

What are positive symptoms?

• An excess of normal function

• Delusions

• hallucinations

What is a Grandiose delusion?

• someone believes that they have special powers, or that they are someone famous.

What is persecution delusion?

• feel like someone is out to get them, as if there is some kind of impending doom, might think you’re trying to poison them when giving them medication.

What is a somatic delusions?

• delusions that happen with the body, Ex: believing that your pregnant, thinking you have a snake as your small intestine.

What is a Nihilistic delusion?

• They don’t feel like they exist, there not there.

What is referential/ ideas of reference delusion?

• where a person believes that something has special meaning to them.

What is religious delusions?

• thinking they are Jesus, try to baptize you or put a curse on you

What is erotomanic delusion?

• believe that someone or something is in love with them.

What are the different types of hallucinations?

¡ Auditory- hearing things that aren’t there. ( talking to themselves, looking over their shoulder, do you hear that)

¡ Visual- seeing things that aren’t there.

¡ Tactile: feeling things that aren’t there.

¡ Gustatory: tasting things

¡ Olfactory: smelling things

What are negative symptoms?

• less than normal function

What is apathy and affect? ( NS)

• Apathy- lack of intrest or desire.

• Affect

  ¡Blunted/flat

What is avolition and Ambivalence?

• Avolition- lack of motivation

• Ambivalence- can’t make decisions

What is Anhedonia and Alogia?

• Anhedonia- lack of pleasure, don’t enjoy the things they once did

• Alogia- lack of speech, not talkative

What is Anergia?

• lack of energy

What is Echolalia?

• repeating things that someone says

What is circumstantiality?

• giving excess details before getting to the point.

What is loose associations:

• thoughts, ideas, and topics aren’t connecting

• sudden shifts without apparent relationship to preceding topics

What is tangentiality?

• going on tangents, never getting to the point.

What is flight of ideas?

• rapid sharing of ideas

• The topic of conversation changes repeatedly and rapidly, generally after just a sentence or phrase.

What is autistic thinking/concrete thinking?

• thinking in a literal sense. An individual has private rules of logic and reasoning that make no sense to anyone else.

• Concrete: Fact-based way to process information, no abstraction. unable to understand punch lines, metaphors, and analogies

what is verbigeration?

• repeating something.

  ( Help, Help, Help)

What is metonymic speech?

• using the wrong word, but it’s connected to the right topic.

• use of words with similar meanings interchangeably

What is clang association?

• repeating similar-sounding words.

• EX: right, light, might, kite

What is Stilted language?

• very formal language.

What is pressured speech?

• pushed language speaking rapidly?

what is mutism?

No speech, just looking at you.

What is disorganized behavior?

• Aggression

• agitation

• Catatonia

  • Stupor, posturing, mutism

    • waxy flexibility

  • Excited subtype: excess movements

• Regressed behavior:

• Bizarre behavior:

• Hypervigilance: staying vigilant

• Echopraxia- do what you do.

What should nursing interventions be aimed at?

¡ Decreasing anxiety and establishing trust

¡ Assisting client to define and test reality

¡ Encouraging interaction with others

¡ Ensuring safety of client and others

¡ Meeting client’s self-care needs

¡ Promoting adaptive family coping

What is a symptom of disturbed sensory perception?

• Hallucinations:

  • Command hallucinations?: being told to do something: go kill yourself, go jump off a bridge, kill this person

What are some nursing interventions for Hallucinations?

¡ Observe for signs of hallucinations: asking them, follow their eyes, are they talking to themselves, itching, kicking something.

¡ Avoid touching client/ warn beforehand

¡ Use acceptance

¡ Help client understand connection between anxiety and hallucinations

¡ Distract from hallucinations:  making sure there not alone, bring them back to reality by tv, music, group.

What is disturbed thought process? Interventions

• disruption in cognitive operations and activities.

• Convey acceptance

• assess the contentWhat

• Do not argue the belief, don’t ply into the delusions

• Reinforce and focus on reality

• With suspicious clients:

  • Promote trust

  • Avoid physical contact

  • Avoid laughing, whispering, etc

  • Be assertive and matter-of-fact

What are some interventions for patients who are that risk for violence to self or others?

¡ Maintain low stimuli environment

¡ Observe behavior frequently

¡ Remove dangerous objects

¡ Keep calm

¡ Have sufficient staff available

¡ Least restrictive environment

What is impaired verbal communication? What are the goals?

žDisorganized speech

žFrequent orientation, short, concrete statements/questions

žGoals: 

¡ Short term- remain on topic, use eye contact for short periods of time

¡ Long term- able to communicate in socially acceptable manner with others

What does recovery-oriented care for person with schizophrenia include?

¡ Teamwork and collaboration: working toward recovery

• Priority care issues

  • Suicide assessment

  • Aggression and safety of patient, staff, others

  • Pharmacologic management

• Psychosocial interventions

  • Cognitive therapy is best when they are stable

  • relaxation, coping skills, building trust, and helping with self-care needs.

What are antipsychotics used for?

• used to decrease agitation and psychotic symptoms.

What are typical antipsychotics ( 1st gen)

• AKA: neuroleptics or conventional

• block dopamine

• help to reduce positive symptoms, do nothing for negative symptoms and might make them worse.

• cheaper and more potent.

What are Atypical antipsychotics ( 2nd Gen)?

• block dopamine and seratonin

• help reduce positive and negative symptoms

What are 3 examples of Neuroleptics ( 1st gen)? routes?

• Haloperidol (Haldol)

• Chlorpromazine (Thorazine)

• Fluphenazine (Prolixen)

• oral and injectables

What are some adverse effects of typical antipsychotics?

• prolactin elevation and gynecomastia

• weight gain

• extrapyramidal symptoms (EPS)

• Neuroleptic Malignant syndrome

What are the two most common EPS in 1st gen meds?

• Pseudoparkinsonism

• Dystonia

• Akathisia

• Tardive dyskinesia

What is pseudoparkinsonism?

• Identical symptoms to Parkinson’s

• Slow movement, trimmers, shuffling gate  because of decrease in dopamine

What is Dystonia/ dystonic reaction? Oculogyric, toticollis, and retrocollis

• Dopamine is decreased rapidly, while acetylcholine is rapidly increasing.

  • Oculogyric crisis: where your eyes are going up

  • Torticollis; the neck is going up

  • Retrocollis: the neck is going to the side

    • Dangerous because it can lead to an impaired area way

• The first sign is a stiff neck

How do we treat dystonia?

Acute:  immediately give anticholinergic– IM or IV

• Benztropine (Cogentin)

• Diphenhydramine (Benadryl)

Long term: daily oral anticholinergic; possible reduce antipsychotic

What is Akathisia?

• Restlessness, “jumping out of skin”, ants in your paints, can’t sit still.

• Most common side effect

• Treat: beta blocker (propranolol)

What is Tardive dyskinesia?

• More common with typical antipsychotics

• Later onset

• Impairment of voluntary movement, constant motion

• no treatment: chart that they have it.

What us Neuroleptic malignant syndrome?

¡ Severe muscle rigidity, mental status changes, autonomic instability (diaphoresis, fever, tachycardia, unstable BP)

¡ Key: early recognition of symptoms & stop medication

¡Treatment:

¡Dopamine agonist (bromocriptine)

¡Muscle relaxant (dantrolene or benzodiazepine)

• Symptom management

• EMERGENCY!!

NMA FEVER?

F: fever

E: encephalopathy

V: vital signs instability

E: Enzyme elevation

R: rigidity of muslces

What are some commonly used atypical antipsychotics? SE

¡Risperidone (Risperdal)

¡Quietiapine (Seroquel)

¡Paliperidone (Invega)

¡Olanzapine (Zyprexa)

¡Ziprasidone (Geodon) take weith food

¡Clozapine (Clozaril)

¡Iloperidone (Fanapt)

¡Asenapine (Saphris)

¡Lurasidone (Latuda) take with food

Side effects:

• weight gain, cardiac arrhythmias, anticholinergic effects, metabolic syndrome, sedation, orthostatic hypotension, hyperprolactinemia

What is Clozapine ( Clozaril)? Labs?

• used when other 2nd-gen meds don’t work

  • Labs: CBC w/ diff at baseline, then absolute neutrophil count (ANC)

    • Continue monitoring after treatment is discontinued

      —Duration depends on the last ANC and any complications

What is the Black box warning for Clozapine ( clozaril)? Signs of infection?

• Agranulocytosis- low WBC production.

• Signs of infection: fever, chills, shore throat, increased HR: agranulocytosis

What is Anticholinergic crisis?

• overdose or sensitivity to drugs with anticholinergic properties.

• Self-limiting: usually subsides 3 days after drug is D/C

What is the treatment for anticholinergic crisis?

¡ Discontinuation of medication

¡ Physostigmine (reversible inhibitor of cholinesterase)

¡ Gastric lavage, charcoal, catharsis for intentional overdoses

What can abrupt cessation of anticholinergic medications due?

• Can yield cholinergic rebound (agitation, confusion, psychosis, anxiety, insomnia, EPS)

What are some psychosocial tx modalities?

• Psychotherapy

  • Reduce stress; build coping skills

  • Recognize triggering situations and behaviors

• Group therapy

• Social skills training

• Case management and social support

What client/family education should be made?

¡ What to expect as illness progresses

¡ Symptoms associated with illness

¡ Ways for family to respond to behaviors associated with illness

• SE of medications

• medication mangement

• when to contact HCP

• relaxation techniques

• social skills traning

What are some support services for clients and families?

¡Financial assistance

¡Legal assistance

¡Caregiver support groups

¡Respite care

¡Home health care

Medication education? the client should…

¡Not stop taking the drug abruptly

¡Use caution re: drowsiness/dizziness

¡Use sunscreen and wear protective clothing when spending time outdoors

¡Report weekly (if receiving clozapine therapy) for blood levels; monitor for signs of infection

¡Rise slowly/ orthostatic hypotension

¡Avoid alcohol

¡Anticholinergic effects

¡Notify doctor if smoking cigarettes

¡Continue taking meds, even if feeling well

Nurse evaluation?

žEstablished trust?

žAnxiety manageable?

žDelusions/hallucinations present?

žCoping skills?

žBehavior appropriate?

žInteracting appropriately with others?

žVerbal communication comprehensible?

žCompliant with meds?

žIsolative?

žAble to complete ADLs?

žAble to utilize resources?

žFollow up care?